Unilateral transversus abdominis plane block and port-site infiltration : Comparison of postoperative analgesic efficacy in laparoscopic cholecystectomy.

PURPOSE: To compare the analgesic efficacy of unilateral subcostal transversus abdominis plane (TAP) block with local anesthetic infiltration, applied to the port site in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Group T received a unilateral subcostal TAP block, group I received a local anesthetic infiltration at port sites, and group C was the control group. Groups T and I received 20 mL 0.25% bupivacaine. Intravenous patient-controlled analgesia with tramadol was similarly applied to all groups. Postoperative pain levels during rest and cough were evaluated using a numeric rating scale (NRS). Nausea and vomiting were evaluated using postoperative nausea vomiting scores (PONV) at 1, 3, 6, 12 and 24 h and tramadol consumption was also determined. Patient satisfaction was evaluated using a Likert-type scale. RESULTS: Postoperative resting NRS scores were lower in group T than the other groups at 1 h and 12 h (p = 0.007 and p = 0.016), while NRS values during cough were statistically significant at 1 h (p = 0.004). The 24­h tramadol consumption was different: group T 229 ± 33 mg, group I 335 ± 95 mg, and group C 358 ± 66 mg (p < 0.001). The percentages of patients reporting that they would prefer the applied postoperative pain control method again were 83.3%, 62.5% and 70.8% in groups T, I and C, respectively (p = 0.118). CONCLUSION: Unilateral subcostal TAP block was superior to local anesthetic infiltration at port sites after LC, in terms of low opioid consumption. Unilateral subcostal TAP block is recommended as part of a multimodal analgesic protocol.

Surgery for colorectal cancer in elderly patients: is there such a thing as being too old?

INTRODUCTION: The overall increase in life expectancy causes a rapid increase in number of elderly patients needing colorectal surgery. It remains unclear if there is a significant risk factor in patients over 80 years of age for postoperative morbidity and mortality. For this reason we investigated the perioperative, outcome and long-term survival after surgery for colorectal cancer in our hospital. MATERIALS AND METHODS: We retrospectively analysed a database containing information about patients who underwent surgery for colorectal cancer from January 2010 to December 2015 at the St. Bernhard Hospital in Kamp-Lintfort, Germany. The last follow-up date was 31th of December 2017. RESULTS: A total of 232 patients were enrolled and analysed in this study. All patients were separated in tow groups depending in age. The first group was ≥80 years old (n=49). The second group was <80 years old (n=183). High ASA-Scores (≥3) were detectable more often in elderly patients (p<0,05). Elderly and young patients had a similar risk for postoperative anastomosic leakages (p=0,047). Likewise there were no significant differences regarding the Dindo-Clavien-Classification (p=0,13). The mortality within the first 30 days after surgery was significant elevated for elderly patients compared to younger patients (p=0,04). Also the overall 1-year survival was 90% for the younger and 73,5% for the older study group (p<0,05) Conclusion. Both the short-term outcome and long-term survival rate after colorectal surgery for cancer are worse for patients older than 80 years of age. After interpretation of all data it remains unclear if the age itself is still the biggest risk factor. When old patients have a good ASA-Score and no severe comorbidities, colorectal surgery remains safe even for patients older than 80 years.

Re-defining the anatomical structures for blocking the nerves in adductor canal and sciatic nerve through the same injection site: an anatomical study.

PURPOSE: The aim of this study is to re-define the anatomical structures which are important for blocking the sciatic nerve and the nerves within the adductor canal which innervate the knee joint through the same injection site. We also aimed to investigate the spread of the anesthetic toward the areas in which the mentioned nerves lie on cadavers. METHODS: This study was performed on 16 lower extremities of formaldehyde-embalmed eight adult cadavers. The anatomy of adductor canal, courses of the nerves within the canal and the relationships of the saphenous, medial femoral cutaneous, medial retinacular, posterior branch of the obturator and sciatic nerves with each other and with the fascial compartments were investigated. Transverse sections that crossed the superior border of vastoadductor membrane were taken to reach the sciatic nerve in the shortest way. Colored latex was injected to demonstrate the anesthetic blockage of the targeted nerves. The structures along the needle's way were investigated. RESULTS: The saphenous, medial femoral cutaneous and at its distal part posterior branch of the obturator nerve were colored with latex within the adductor canal. The nerve to vastus medialis (in other words, the medial retinacular nerve) lay beneath the fascia of vastus medialis and did not enter the adductor canal. There was a fascial plane which did not allow the passage of colored latex toward the sciatic nerve. To traverse this fascial structure, it was found out to be necessary to insert the needle perpendicular to both the vertical and transverse axes of the thigh and then advance it along 2/3 of diameter of the thigh. Thus, the colored latex was observed to fill the compartment where the sciatic nerve lay within. CONCLUSIONS: Blocking the sciatic nerve and the nerves within the adductor canal which innervate the knee joint through the same injection site seems anatomically possible without injuring any neurovascular structures.

Ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in chronic pelvic pain.

Chronic pelvic pain is a condition that can be caused by pudendal neuralgia, interstitial cystitis, piriformis syndrome and neuropathy of the ilioinguinal, iliohypogastric and genitofemoral nerves. Based on three case reports this article discusses the clinical effectiveness of pulsed high-frequency radiofrequency (PRF) treatment applied to the pudendal nerve under ultrasound guidance in medicinally treated patients with chronic pelvic pain.

Effect of two surgical circumcision procedures on postoperative pain: A prospective, randomized, double-blind study.

BACKGROUND: Male circumcision (MC) is one of the most commonly used surgical procedures worldwide for medical and traditional reasons. No studies have compared the postoperative pain advantages of conventional techniques (i.e., sleeve and dorsal slit). OBJECTIVE: In this prospective randomized double-blind study, we investigated the effect of two surgical techniques (i.e., sleeve and dorsal slit) on postoperative pain and emergence agitation. STUDY DESIGN: This prospective study was conducted between January and July 2013. Approval was obtained from the local Ethical Committee on 17 December 2012, 06/23 (CLINICAL TRIALS IDENTIFIER: NCT 01909765). We compared two surgical techniques (i.e., the dorsal slit incision technique (Group A) and the double incision (i.e., sleeve) technique (Group B) in 60 children who were subjected to MC surgery under general anesthesia. All children received dorsal nerve blocks with bupivacaine. The modified objective pain scale (MOPS) was used for pain assessment, and the Ramsey Sedation Scale was used for the assessment of agitation during anesthesia emergence. RESULTS: The MOPS scores were lower in Group B than in Group A in the post-anesthesia care unit and during the 4th hour post-surgery (p = 0.01 and p = 0.037, respectively). Twelve children (40%) in Group A and 23 children (76.6%) in Group B required no additional analgesia on postoperative day one (p = 0.004). The Ramsey sedation scores were lower in Group A (p = 0.018). DISCUSSION: Dorsal slit is often the primary method in cases with paraphimosis; during this procedure, the frenulum frequently cannot be preserved at the 6-o'clock position of the mucosa, because of traction applied to skin and mucosa. As a result, the frenular artery is injured. In contrast, the sleeve technique protects the frenulum and the anatomic structures of the glans. In the sleeve technique, providing hemostasis and preventing partial ischemia by protecting the frenular artery reduces postoperative pain and complications. This present study demonstrated that the sleeve technique, which preserved the frenular artery, caused less bleeding, reduced electrocautery use and less ischemia than the dorsal slit technique. The sleeve technique effectively reduces early postoperative pain and agitation after circumcision, provided that adequate postoperative analgesia has been achieved. While all variables except the employed surgical techniques were similar, Group B had advantages with respect to analgesic requirement and pain control during the first 8 h after the operation. CONCLUSION: The sleeve technique provides lower pain scores and a reduced incidence of agitation after elective MC.

Effect of ultrasound-guided intercostal nerve block on postoperative pain after percutaneous nephrolithotomy : prospective randomized controlled study.

BACKGROUND: The aim of the study was to investigate the effect of preoperative ultrasound-guided (US) intercostal nerve block (ICNB) in the 11th and 12th intercostal spaces on postoperative pain control and tramadol consumption in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS: After obtaining ethical committee approval and written informed patient consent, 40 patients were randomly allocated to the ICNB group or the control group. For the ICNB group US-guided ICNB was performed with 0.5 % bupivacaine and 1/200,000 epinephrine at the 11th and 12th intercostal spaces after premedication. A sham block was performed for the control group and postoperative pain and tramadol consumption were recorded by anesthesiologists blinded to the treatment. RESULTS: Postoperative visual analog scale scores at all follow-up times were found to be significantly lower in the ICNB group than in the control group (p < 0.05). The mean 24 h intravenous tramadol consumption was 97.5 ± 39.5 mg for the ICNB group which was significantly lower than the 199.7 ± 77.6 mg recorded for the control group (p < 0.05). CONCLUSION: In PCNL with nephrostomy tube placement US-guided ICNB performed at the 11th and 12th intercostal spaces provided effective analgesia.

Addition of lidocaine to bupivacaine for spinal anaesthesia compared with bupivacaine spinal anaesthesia and local infiltration anaesthesia.

BACKGROUND: Two spinal anaesthesia techniques were compared with local infiltration anaesthesia (LIA) to test the hypothesis that the addition of lidocaine to bupivacaine would decrease the spinal block's duration and provide shorter recovery to discharge. METHODS: Ninety-three patients undergoing outpatient herniorrhaphy were randomised into three groups. Spinal anaesthesia: the BL Group (bupivacaine-lidocaine) received 2 ml hyperbaric bupivacaine (10 mg) + 0.6 ml 1% lidocaine (6 mg), the BS Group (bupivacaine-saline) received 2 ml hyperbaric bupivacaine (10 mg) + 0.6 ml saline. LIA: the LIA group received plain bupivacaine + lidocaine. Resolution of the nerve blocks were compared between spinal anaesthesia groups, and post-operative pain scores, analgesic requirements, post-anaesthesia care unit (PACU) time, and discharge time were compared among all groups. RESULTS: Spinal block resolved faster in the BL group vs. the BS group: 194.8 [standard deviation (SD) 29.2] min vs. 236.8 (SD 36.5) min (P = 0.000). PACU and discharge time were shortest in the LIA group [PACU time: 108.7 (SD 27.6) min vs. 113.0 (SD 39.4) min and 151.9 (SD 43.7) min in the BL and BS groups (P = 0.000), and discharge time 108.5 (SD 29.5) min vs. 145.8 (SD 37.3) min and 177.1 (SD 32.0) min in the BL and BS groups, respectively (P = 0.000)]. Pain scores and analgesic consumption were lower, with the time to first analgesic intake being longer in the LIA group. CONCLUSION: Addition of lidocaine to bupivacaine reduced the duration of the spinal block and was associated with shorter recovery times. However, LIA provided the fastest recovery to discharge after outpatient inguinal herniorrhaphy.

Propofol sedation in total knee replacement : effects on oxidative stress and ischemia-reperfusion damage.

PURPOSE: This study aimed to show the effect of propofol sedation on oxidative stress and inflammation resulting from ischemia-reperfusion. METHODS: After having obtained written informed consent from the patients and ethics committee approval, 36 patients were randomly allocated to 2 groups: group C, control and group P, propofol. Spinal anesthesia was administered to both groups with 15 mg bupivacaine. Patients in group P received a propofol infusion of 2 mg/kgBW/h and the patients in group C received a placebo infusion in an equal dose. Malondialdehyde (MDA), superoxide dismutase (SOD) and the total antioxidative capacity (TAC) levels were measured in venous blood samples prior to propofol or placebo administration (preischemia T0), 30 min after placing the tourniquet (ischemia T1) and 2 h after deflation of the tourniquet (reperfusion T2). High sensitivity C-reactive protein (hsCRP) and neutrophil levels were measured before propofol was administered (T0) and 12 h after reperfusion (T3). RESULTS: While serum MDA and SOD levels were significantly higher during the reperfusion period than the preischemic period, TAC levels were found to be low in the control group (p < 0.05). In the propofol group there were no differences between the preischemia-reperfusion periods with respect to MDA, SOD and TAC levels (p > 0.05). The neutrophil and hsCRP levels were observed to be increased to a lesser extent in the propofol group compared to the control group (p < 0.05). CONCLUSIONS: Propofol infusion in addition to spinal anesthesia may reduce oxidative damage and the inflammatory response developing due to the tourniquet in total knee replacement surgery.

Neurolytic phenol blockade of the obturator nerve for severe adductor spasticity.

BACKGROUND: In this study, we present the 3-month follow-up results of a retrospective analysis of obturator nerve (ON) phenol neurolysis performed between 2000 and 2007 in patients with adductor spasticity. METHODS: The study was performed by retrospective investigation of the clinical follow-up results of 80 ON phenol treatments in 62 patients. Neurolysis using 5-10 ml 6% phenol was applied with the guidance of fluoroscopy and a peripheral nerve stimulator. Pain, spasticity and hygiene were evaluated and the hip abduction range of motion (ROM) was measured at the end of the first week and in the first, second and third months following the intervention. RESULTS: The visual analogue scale scores decreased significantly in the first week, first month and the second month, but reached their initial values in the third month. A drastic increase in the ROM values was shown in hip abduction in the first week, first month and second month. An increase in the Ashworth Scale values was observed in the second and third months, but they did not reach their initial values. The hygiene score decreased drastically in the first week and the first and second months, but worsened in the third month. The success rate in nerve localization during ON neurolysis was 100%. CONCLUSION: ON phenol blockade with fluoroscopy and peripheral nerve stimulator guidance in patients with adductor spasticity led to a decrease in spasticity and pain with an increase in the ROM of the hip and better hygiene with an efficacy lasting for about 3 months.

Ultrasound-guided botulinum toxin type A injection to the iliopsoas muscle in the management of children with cerebral palsy.

OBJECTIVE: To determine the effect of botulinum toxin type A (BTX-A) on spasticity and functional development in children with cerebral palsy (CP) in conjunction with a physiotherapy program. METHOD: In this prospective study, 18 CP patients were evaluated. Multilevel BTX-A injection was applied to children at a dose of 15 U/kg. Children were assessed before and at the 5th and 12th week post-injection using Thomas test, Duncan-Ely test, passive range of motion (pROM) measurement, Distance Between Knee (DBK), Selective Motor Control (SMC) scale, modified Ashworth Scale (MAS) and modified Physician Rating Scale (mPRS). To assess functional improvement, Gross Motor Function Measure (GMFM) and Functional Independence Measure for Children (WeeFIM) were used before and at the 12th week post-injection. RESULTS: At 5th week post-injection, a statistically significant decrease was determined in spasticity (p < 0.01). Improvement was observed in mPRS and pROM, but not in SMC. At the 12th week post-injection, GMFM (p< 0.001) and WeeFIM improved significantly (p< 0.001). The improvement in pROM and mPRS (p< 0.01) lasted until the 12th week post-injection, but the improvement in MAS (p > 0.05) and in the Tardieu test of hip adductors (p > 0.05) did not last after the 5th week. CONCLUSION: BTX-A injection enhances functional and motor abilities in the development process.

The location of the obturator nerve: a three-dimensional description of the obturator canal.

Satisfactory analgesia cannot be achieved in every obturator nerve block. To attempt to improve the success rate of obturator nerve block, this study describes the detailed anatomy of the obturator region and canal. Eleven (5 female and 6 male) cadavers, totally 22 sides were dissected. Anatomical positions of the structures entering and leaving the canal were defined. The position of the obturator nerve and its branches and their relation with the obturator artery, vein, and with the internal iliac and femoral veins were investigated. A mould of the canal and a model were created. Detailed measurements were performed on the cadavers and models. The obturator canal was in the shape of a funnel compressed from superior to inferior, with anterior and posterior openings. At the entrance of the canal, the nerve lay superiorly; the artery was in the middle, and the vein lay inferiorly. The obturator nerve ran close to the lateral wall of the obturator canal. The distance of lateral wall of obturator canal to the median plane was 41.4 +/- 1.1 mm. After leaving the canal, the nerve lay laterally while the anterior branch of the artery was medial. A venous plexus lay between the two structures. The presence of the branches of the obturator artery and vein alongside the obturator nerve may increase the risk of injury to these structures during anaesthetic procedures. The anterior division of the obturator nerve has a close relationship with these vessels. To provide complete analgesia, the obturator nerve should be blocked in the obturator canal or at its external orifice.

Detailed anatomy of accessory obturator nerve blockade.

BACKGROUND: The accessory obturator nerve (AON) often innervates the hip joint and adductor longus. The AON is present in 10-30% of patients, and thus it is clinically important that it is also considered during obturator nerve (ON) blockade. METHODS: The study was performed on 12 cadavers (24 body-sides) and the AON beginning from the lumbar plexus was observed. The needle was classically penetrated into the ON to gain access to the AON and upon definition of detailed AON anatomy, morphometric measurements were conducted. In addition, novel maneuvers used in the study were described. RESULTS: Throughout the dissections, the AON was detected on three sides (12.5%) and the mean AON- pubic tubercle distance was measured as 4.0 cm. The needle was withdrawn and positioned medially and almost parallel to the skin. It was then advanced through the superior pubic ramus to reach the AON. CONCLUSION: Owing to its anatomical structure, the AON can be easily accessed during classical ON blockade using the maneuvers described here. Further clinical studies are needed to investigate if supplementing ON blockade with AON blockade might improve the clinical efficiency and quality of the blockade.